Intolerance to Enteral Nutrition
OVERVIEW
- Intolerance to enteral nutrition is characterised by excessive aspirates (>500mL q6h),vomiting, abdominal distension, constipation or diarrhoea
CAUSES
Patient
- GORD
- hiatus hernia
- gastroparesis/ileus
- pseudo-obstruction
- retroperitoneal haematoma/oedema
- bowel injury
- bowel ischaemia
- shock
- sepsis
- pancreatitis
- bowel obstruction
- hyperglycemia
- hypoxia / ischemia
- trauma
- burns
Mechanical
- NGT not placed in stomach
- kinking
- blockage
Drugs
- opioids
- sedation
- no prokinetics
- hyperosmolar formulas
ASSESSMENT
History
- sedation/analgesia: hold?
- history of symptoms
- discussion with surgeon
- search for sepsis, pancreatitis, MI, GI pathology, cause of shock
Examination
- to find above pathologies
Investigations
- AXR
- CXR (erect)
- CT abdomen
MANAGEMENT
General approach
- rule out bowel obstruction
- minimize drugs causing gastroparesis or ileus
- correct electrolytes
- start at low volumes with steady increases until goal rate achieved
- prokinetics
- consider NJ feeding
- TPN
Approach to gastric residual volumes >500mL q6h
References and Links
LITFL
- CCC — Prokinetics
- CCC — Gastric Residual Volume
Journal articles
- Deane A, Chapman MJ, Fraser RJ, Bryant LK, Burgstad C, Nguyen NQ. Mechanisms underlying feed intolerance in the critically ill: implications for treatment. World J Gastroenterol. 2007 Aug 7;13(29):3909-17. PMID: 17663503.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
2 Comments
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I have been searching for help. My 36 year old son was born with cystic fibrosis. He had his first double lung transplant at 15. He had his second double lung transplant at 25. He under went a third double lung transplant at 35 this past September 13th 2020.
He has been in ICU at Toronto General Hospital for 5 months with many challenges. He has a trach, is on dialysis yet slowly he is getting stronger. The biggest problem has been feeding intolerance. Since October he has battled gas, bloating, diareaha, and is still not able feeds. Any recommendation would be greatly appreciated.
Hi Tanis, sounds like you and your son have had a really hard time of it. His situation sounds incredibly complicated and it’s not our place to offer specific advice here. I’m sure the team in Toronto would be looking at the usual options and it’s best to take it up with them.